St Catherines Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. The registered manager listened to concerns about safety and investigated and reported safety events. Lessons had been learnt to continually identify and embed good practice. Accidents and incidents were recorded and analysed to identify trends and patterns to mitigate future risks. We saw the registered manager continually looked at ways to learn from events and sought guidance. For example, following a high number of incidents in the home, the management team and the provider had improved systems to ensure they were fully reviewed, analysed and lessons were learnt. Learning actions for staff were discussed at team meetings.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. We saw evidence in care plans of visits and referrals when required. We were shown staff could produce an emergency pack which would be used to pass on relevant information to healthcare professionals when required.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. Staff understood safeguarding procedures and reported incidents immediately to management.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People's capacity was assessed in line with MCA and decisions were made, where people did not have capacity, in their best interest. People had Deprivation of Liberty Safeguards (DoLS) in place to protect their rights and the service complied with these.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks associated with people’s care were not consistently managed. Risks linked to people’s care had been identified, but staff did not always follow the plans to manage these risks. For example, where people had lost weight, this was not always consistently picked up in reviews, and food records did not show snacks were offered or document the amount of food people had eaten. Therefore, it was not possible to effectively monitor or evaluate to manage risks safely. We raised these concerns with the registered manager who took swift actions to keep people safe.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. We found areas of the home required attention to ensure peoples safety. For example, fire exits were not kept clear, leaves and discarded work materials were seen and the external access to the garden was not safe because it required an accessible ramp. These were addressed immediately following our visit.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. The provider had a recruitment process in place which supported them to recruit staff who were suitable to work with vulnerable people. Staff received training and support to carry out their roles effectively. There were sufficient staff available to support people in line with their needs.

The provider did not always assess or manage the risk of infection. During a tour of the home, we found most areas were clean. However, some items were poorly maintained and could not be cleaned properly. These included shower chairs, lounge chairs, pressure cushions, dining chairs, a microwave and a fridge. The registered manager told us they had ordered new chairs and pressure cushions. They later confirmed the other issues had been addressed. They also updated the cleaning schedule to help prevent these areas from being missed again.

Staff had access to appropriate stores of personal protective equipment (PPE). Members of staff had access to infection prevention and control policies.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medicines as prescribed. The provider had policies and procedures in place to support the safe management of medicines, and staff had received appropriate training to administer medicines safely. In addition, the clinical lead supported nursing staff to improve their skills and competencies. We identified some minor concerns with medicines management which the registered manager addressed immediately to mitigate risk. They have since completed an audit and an action plan.